Perioperative Mortality

June 17th, 2015 at 10:00 am by David Farrar

An interesting report on perioperative mortality in NZ. It’s great that we have such transparency of data.

The mortality rates within 30 days of an operation are:

  • Coronary artery bypass graft 2.47%
  • Percutaneous transluminal coronary angioplasty 1.66%
  • Hip arthroplasty 1.58%
  • Cholecystectomy 0.37%
  • Knee arthroplasty 0.17%
  • General anaesthesia 0.12%
  • Bariatric surgery 0.07%

There is a huge difference based on you ASA score. The ASA scores are:

  1. Healthy person 0.05%
  2. Mild systemic disease 0.05%
  3. Severe systemic disease
  4. Severe systemic disease that is a constant threat to life 16.9%
  5. A moribund person not expected to survive without the operation 52.8%
  6. A brain-dead person

 

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DHBs improve towards health targets

May 27th, 2015 at 2:00 pm by David Farrar

Jonathan Coleman released:

Health Minister Jonathan Coleman says the latest quarterly health target results show the shorter stays in emergency departments target has been met for the first time.

“DHBs are continuing to improve their performance on the Government’s health targets,” says Dr Coleman.

“Across the country over 250,000 New Zealanders were admitted, discharged or transferred from an emergency department within six hours. Achieving the 95 per cent target for the first time is a significant achievement.

“The number of patients presenting to emergency departments continues to increase. In quarter three, 4,481 more people attended an emergency department compared to the last quarter.

“Reaching the target is a tribute to all the staff working within emergency departments and DHBs. We know that emergency departments only work well when the rest of the hospital is working well too.”

The improved access to elective surgery and the hospital component of the better help for smokers to quit targets were also met:

Here’s the latest national data, and how it compares to the past:

  • ED treatment within six hours – 95%, up from 70% in 2008
  • 123,585 elective surgical procedures in 9 months compared to 118,000 for all of 2008
  • 67% get cancer treatment within 62 days of referral
  • 100% get radiotherapy or chemotherapy within four weeks of decision to treat, up from 65% in 2008
  • 93% of infants immunised compared to 76% in 2008
  • 96% of hospitalised smokers given advice on how to quit, up from 17% in 2010
  • 89% of smokers seeing a primary care professional given advice on ow to quit, up from 30% in 2013
  • 88% of eligible population have had a cardiovascular risk assessment in last five years, up from 46% in 2012

Once again we see the benefit of having a health system focused on eight or so goals, rather than the 50+ there were under Labour, almost none of which were achieved.

The real credit should go though to the doctors and nurses in the DHBs and primary care professionals. They’re done really really well to get such improvements, backed up by extra funding.

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5,500 more doctors and nurses

May 21st, 2015 at 7:00 am by David Farrar

healthworkforce

The graph shows the increase in full-time equivalent doctors and nurses in our public health (DHBs) system. Considering the impact of the GFC, and the need to get back into surplus, that is a significant achievement.

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$98 million more for surgery

May 7th, 2015 at 11:56 am by David Farrar

Jonathan Coleman announced:

An extra $98 million will be invested in Budget 2015 to provide more New Zealanders with timely elective surgery, and to improve the prevention and treatment of orthopaedic conditions, Health Minister Jonathan Coleman says.

“Access to elective surgery is a top priority for the Government. Elective surgery makes a real difference to patients and their families – it reduces pain, increases independence, and improves quality of life,” Dr Coleman says.

“The number of patients receiving elective surgery has increased from 118,000 in 2007/08 to 162,000 in 2013/14. That’s 44,000 more operations – a 37 per cent increase.

Considering the fiscal circumstances of the last few years, that’s a very significant increase. There will always be unmet demand, but there has been significant extra funding over the years to increase capacity.

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Much ado about nothing

April 21st, 2015 at 1:04 pm by David Farrar

Stuff reports:

Not all children will receive free GP visits as promised by the Government, according to documents revealed by the Greens.

That’s because they have never promised it. It is impossible to promise it as GPs do not work for the Government and the Government can not set their fees for them – unless you nationalise the entire primary healthcare sector.

ACC Minister Nikki Kaye has set the funding level at a rate that will only cover an estimated 90 per cent of doctors’ visits for children who are injured, Radio NZ has reported.

At last year’s election the Government campaigned on making doctors’ visits and prescriptions free for all children under 13 from July this year.

However the Green Party has called out Kaye for deciding 90 per cent coverage was close enough.

This shows a misunderstanding (either deliberate or not) of how the funding level is set.

GPs around NZ will currently charge a wide variety of fees for under 13s. For example some may charge $10 and some may charge $30. Each GP practice can be different to reflect their costs – rent, salaries etc. These are different in Epsom and in Rotorua, for example.

The Government set the funding at the level at which 90% of GPs are currently charging. Now this doesn’t mean that 10% of GPs will still charge a fee. If for example the subsidy is $30 and your charge was  $32, you may well decide that it is not worth the hassle, or the bad publicity, to charge a $2 part fee.

Over time more and more GPs will not charge a part fee, because if they do it is bad publicity, and patients may move.

Coleman and Kaye point out:

“We expect levels of uptake by general practices of the free under 13s scheme to be similar to uptake of the under 6s scheme,” says Dr Coleman.

“Currently 98 per cent of general practices offer free doctors’ visits for under 6s. Initial uptake was 70 per cent in January 2008, and it has steadily increased to current levels. There are only around twelve general practices in New Zealand that are not offering free under 6s doctor visits.”

So the fact the funding is set slightly below the level at which the 10% most expensive GPs charge, doesn’t mean you don’t get close to universal coverage.

But less us look at what the Greens are actually arguing for, and you will see that they are actually arguing for an incredibly appalling waste of scarce health dollars.

They are saying that the level of subsidy should be set at the level above which 100% of GPs currently charge.

Now think about that. The Greens are saying that the subsidy to GPs should be based on what the most expensive GP in NZ charges.

This would result in a massive wealth transfer to GPs. 99% of GPs would get a higher subsidy from the Government, than they were previously getting from patients. This would cost tens of millions of dollars.

And what would be the benefits to families? Well possibly it could result in no part-charges to the families who live in the areas with the most expensive GPs. These are generally the very wealthy suburbs such as Epsom, Wadestown etc. So the richest families in NZ would be the ones who benefit by not having a small part-charge.

I don’t have the exact numbers, but a ballpark estimate is that the cost per additional family subsidised to taxpayers and levypayers would be over $1,000!

You would be spending tens of millions more to eliminate part-charges for a handful of the wealthiest families.

The losers would be every family in NZ who pays tax and ACC.

The winners would be every GP in NZ, and the families who live in the wealthiest areas.

A huge transfer of wealth from middle income and low income NZ to the wealthiest. What the Greens call income inequality – and they are demanding it.

So I’m glad the Greens aren’t in Government, and that the subsidies are set at a sensible point such as the 90% level, rather than having the most expensive doctor in NZ determine the subsidies for the entire country.

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A misleading story

April 5th, 2015 at 2:00 pm by David Farrar

Stuff reports:

Seeing a doctor is becoming a luxury item as housing costs take a toll on family budgets, Christchurch social agencies say.

“We have a number of families who don’t even take their children to the GP until they get really sick and often that’s because they’ve got debts and doctors sometimes won’t see a family until they have cleared previous debts,” Christchurch Methodist Mission executive director Jill Hawkey said.

I don’t know of any GP that will refuse to see a child because the family owe them money. They may ask the parents to arrange to pay their debts, but they won’t refuse to see a child.

One family with an outstanding bill of $30 were threatened by debt collectors with fees in excess of $1000 unless they paid up, she said.

That sounds preposterous, and I doubt it.

Nine practices in Canterbury operate under the Government’s Very Low Cost Access (VLCA) scheme and 298 Youth Health Services provides free GP visits for 10-24-year-olds.

It is worth remembering that taxpayers not subsidise free GP visits for children up to the age of 13.

This story is based on anecdotes and claims by an NGO. It would be a better story if it referenced actual data, such as the annual NZ Health Survey by the Ministry of Health. The latest survey finds:

  • children who did not visit a GP due to cost in the last year decreased from 6.3% to 5.2%
  • children who did not visit an after hours service due to cost decreased from 4.5% to 3.6%

I’m not saying there shouldn’t be an article on the claims that some families can’t afford primary healthcare. What I’m saying is that the article just repeated claims that had no substance, and didn’t seek out any data that contradicts that.

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What should the public health system fund?

February 20th, 2015 at 2:00 pm by David Farrar

Stuff reports:

The letter comes after Christchurch weight loss blogger Elora Harre, posted on her Facebook page, the Shrinking Violet, that she had been refused excess skin removal surgery during a consultation with a plastic surgeon at Christchurch Hospital on Friday.

She was told she was a “perfect candidate” but the hospital lacked resources to operate, she said.

“Why is it that despite the fact we are quickly becoming an obese nation, for someone who has done what I was asked and lost the weight that could’ve cost our public health system A LOT more, that there is no resource for me?” she wrote.

She said the excess skin on her stomach, inner thighs, calves, lower back, arms, breasts and armpits caused her both psychological discomfort and physical discomfort, including a recurrent staph infection in her navel.

The post, which has attracted more than 600 “likes”, called on her thousands of followers to email Christchurch hospital general manager Pauline Clark and Minister of Health Jonathan Coleman in support of her cause.

I have some sympathy for Ms Harre’s cause. By losing weight naturally she has saved the health system money, and specifically could have been eligible for gastric bypass surgery which is very costly. It would arguably be a nice incentive that if you lose weight without surgery, you could qualify for some cheaper cosmetic surgery to remove excess skin.

However with limited resources it is hard to argue it is a priority:

Christchurch Hospital’s clinical director of plastic surgery has responded to criticism from a woman who was refused excess skin removal following her 55-kilogram weight loss.

In a letter to Stuff.co.nz, Dr Barnaby Nye wrote of the challenge of delivering health care in a budget-constrained environment. …

In his letter, Nye did not wish to comment on individual cases, but offered hypothetical case studies of patients he may treat, including a woman with carpel tunnel syndrome, and a man requiring jaw reconstruction after cancer removal.

“Every one of these patients lives will be improved with surgery,” Nye wrote.

“We are tasked with drawing a threshold to treat patients in the public system and must weigh the benefits for each of these … Our budget demands a certain number of cases be done per year but with limited operating time, operating on [one person] potentially denies more than 30 [other people] the chance of treatment.”

It is hard to say that the clinicians have their priorities wrong.

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Our improving health

December 24th, 2014 at 10:00 am by David Farrar

The annual NZ Health Survey was published this month. It is interesting to compare results with 2006/07. These include:

  • Over 75s who say they are in good or better health up from 80% to 87%
  • Smoking rate down from 20% to 17%
  • Under 18 smoking rate down from 16% to 8%
  • Hazardous drinking rate down from 18% to 16%
  • Under 18 hazardous drinking rate down from 20% to 14%
  • 18 – 24 year old hazadrous drinking rate down from 43% to 33%
  • Under 18 drinking rate down from 75% to 59%
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Issues that matter – Health

September 12th, 2014 at 1:00 pm by David Farrar

cancer

 

In 2008 only 65% of people requiring cancer treatment got it within four weeks. Many had to go to Australia to get treatment. Today every DHB has 100% of people needing cancer treatment getting it within four weeks. Source: Ministry of Health National Health Targets.

smoking

 

The best way to reduce smoking, is for young New Zealanders not to take it up. In 2007 15.7% of 15 to 17 year olds were smokers. In 2013 this rate had reduced to 8.0%. Source: Ministry of Health Public Health Survey. Note I don’t think this change is not necessarily related to who is in Government, but think it is important to make the point that the trend is very positive.

surgery

 

In 2008 the public health system provided 118,000 elective operations. In 2013/14 it was 161,933. A huge increase of 44,000. Source: Ministry of Health National Health Targets.

Surgery Growth

 

From 2003 to 2008 the number of elective operations increased by 2,950 a year. Since 2008 it has increased by 7,368 a year. Source: Ministry of Health National Health Targets and National Party.

youthdrinking

 

Recall all the moral panic over youth drinking.  Well the Ministry of Health Public Health Survey shows that in 2007 19.5% of 15 to 17 year olds were hazardous drinkers and in 2013 only 8.1% were – almost half as many. Source: Ministry of Health Public Health Survey.

workforce

 

That’s 3,289 more nurses, 1,589 more doctors and 1,000 fewer health managers and administrators since 2008. Source: National Party Health Policy.

workforce2

 

This is the change in percentage terms. Source: National Party. A 17.8% increase in nursing numbers and 26.8% increase in doctor numbers.

ED

 

In 2008 only 70% of people in Emergency Departments were treated within six hours. In 2014 it was 94%. Source: Ministry of Health National Health Targets.

immunisations

 

In 2008 only 76% of two year olds were immunised (on time). In 2014 it was 93%. Source: Ministry of Health National Health Targets.

These are not abstract changes. These are changes that make a huge impact on people’s lives. Few things are more important than quick cancer treatment, shorter emergency department stays, more immunisations and more elective operations. Plus on top of that the youth rates for smoking and hazardous drinking has almost halved.

These are issues that matter.

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Stuff that matters – cancer treatment

August 29th, 2014 at 10:00 am by David Farrar

Tony Ryall announced:

If your doctor suspects you have cancer, the Government will ensure you see a cancer specialist and receive treatment faster than ever before. …

“We inherited cancer services which were failing New Zealanders. Patients were waiting months for treatment and some had to travel to Australia because of lengthy delays here. Thankfully those days are over – all patients now receive radiotherapy and chemotherapy treatment within four weeks of being ready to treat.

“We will build on our successful plan and introduce a new national health target which will ensure cancer patients receive their diagnostic tests, surgery, chemotherapy and radiotherapy even faster.

“If your GP suspects you have cancer, you should see a cancer specialist within two weeks. Diagnostic tests and clinical investigations will be completed in a faster, more streamlined way and our goal is for patients to receive their first cancer treatment within a maximum 62 days of their original GP’s referral.

“The new target is much broader than the current cancer health target, which focuses on how long patients wait to start their chemotherapy and radiotherapy when ready to treat. The current cancer target didn’t include surgery, which is often the first treatment step for patients, or the time patients wait to see a cancer specialist and have tests done.

“The maximum 62 days is an international gold standard for cancer treatment. Currently in New Zealand around 60-65 per cent of patients receive their first cancer treatment within this time.

“The new target will be for 90 per cent of patients to receive their first treatment within a maximum 62 days of seeing their GP by June 2017.

This is stuff that matters.

Cancer waiting times were abysmal under the last Government. Not on purpose, but because the health system had little clear focus. With something like 100 different health targets, it was a mess.

Ryall has managed to focus the health system on a few achievable but very important targets such as faster treatment for cancer, more immunisations, quicker A& visits, more elective surgery, better quit smoking help, and more health checkups. And the great thing is that doctors and nurses and health managers have shown an ability to meet, and sometimes exceed, these targets when they are have a clear focus.

This stuff literally saves lives.

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A sensible oldie

August 12th, 2014 at 10:00 am by David Farrar

The Herald reports:

There were tough questions, soft questions, and sometimes no questions at all as Labour leader David Cunliffe took to the Auckland suburbs of Glen Innes, Onehunga and Tamaki yesterday to sell the party’s policies.

Fresh off his announcement that all over-65s, pregnant women and children under 13 would get free GP visits and prescriptions, Mr Cunliffe visited Onehunga Mall.

But it was a shaky start, as a gentleman threw up his hands in a flutter in an attempt to avoid shaking Mr Cunliffe’s hand.

And Colleen Whitehouse, 77, said she didn’t want Labour’s healthcare policy. “I think it would cost the country too much money.”

It wold, and far more than they say. Labour constantly make the mistake of never allowing for the fact that if you don’t charge for something, then far more people will use it.  Student associations used to give away free “hardship” money and every year they would report how surprised they were that more and more students would turn up wanting free money.

hardshipbyage

This graph is from the Dim Post, where Danyl points out:

Labour’s policy is a generous subsidy to the least needy group in the country. It’s also a very large group of people with high health-care needs and giving them ‘free’ access to healthcare is going to cause a huge increase in demand for primary health services.

Labour is promoting higher taxes on families and businesses of up to $5 billion a year, so they can increase subsidies to the “least needy”. Our aging population already poses massive fiscal challenges to us in terms of affordable healthcare and superannuation. Labour’s policy will make future healthcare even more unaffordable.

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Labour’s health promises not well targeted

August 11th, 2014 at 9:00 am by David Farrar

Stuff reports:

Labour is promising 1.7 million people – 40 per cent of the population – will be eligible for free doctors visits and prescriptions under a Labour-led government.

Leader David Cunlifffe announced the plan today at his campaign launch in Auckland saying the September 20 election was about a choice between prosperity for all or only for a few.

“After another three years heading in the direction we’re heading we just won’t know this country. Our rivers will be dirty. What’s left of our assets will be sold, and so will vast tracts of our land. We will be tenants in our own country,” Cunliffe told the 800 strong audience, in a reference to the recent controversy over farm sales to foreigners.

The major health package includes free doctors visits and prescriptions for almost 700,000 people aged over 65 at a cost of $120m.

This is a massively mis-targeted policy which is entirely about votes, not health.

The Ministry of Health done an annual health survey. One of their questions is whether someone has not gone to see a GP in the last year due to the cost. Here is the breakdown, in order, by age:

  • 25 – 34: 22.3%
  • 35 – 44: 17.8%
  • 15 – 24: 15.8%
  • 45 – 54: 13.9%
  • 55 – 64: 12.1%
  • 65 – 74: 6.3%
  • 75+: 4.7%

So Labour’s policy is not just slightly badly targeted – it is as far away from the area of most need as possible. They are saying we must provide free GP visits to the age group that has the least problem paying. It’s is purely about middle class welfare votes, not about health.

What about free presciptions? Here’s the breakdown by age again of those who did not get a prescription filled because of cost:

  • 25 – 34: 7.6%
  • 45 – 54: 7.5%
  • 35 – 44: 7.2%
  • 15 – 24: 6.1%
  • 55 – 64: 5.6%
  • 65 – 74: 3.2%
  • 75+: 1.9%

Also the Health Survey shows a positive trend for prescriptions, not a worsening one. The proportion of elderly not being able to afford to get their prescriptions filled dropped by a quarter to a third in the last year.

So again Labour policy is aimed at those with the least problem paying. It is a very cynical costly bribe.

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Greens promising an extra $280 million a year of health spending

May 31st, 2014 at 12:10 pm by David Farrar

The Greens have announced:

The Green Party today launched a $29 million plan to improve the health of young people aged 13-17, including making GP visits free for this group.

This is on top of their promise of $100 million for health hubs in schools, $100 million for “retaining health care capacity” and $50 million for higher wages.

That’s $280 million a year just on one policy – which is basically the entire surplus gone. So are they going to raise taxes, or have us stay in deficit?

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Patients getting a say on hospitals

May 13th, 2014 at 10:00 am by David Farrar

Tony Ryall and Jo Goodhew announced:

From July, patients will have the opportunity to provide feedback and rate their experiences in hospital – a move welcomed by Health Minister Tony Ryall and Associate Health Minister Jo Goodhew.

“DHBs will be running a quarterly survey of patients to find out what they think about their most recent stay in hospital,” says Mr Ryall.

“The survey has 20 questions covering issues such as whether patients understood the advice they were given by their doctor, whether they were involved in decisions about their care and treatment, and whether they were treated with respect and dignity by hospital staff.

“Responses will be collated to give each DHB a rating out of 10 in four areas: coordination, partnership, communication, and physical and emotional needs,’ says Mr Ryall. 

Mrs Goodhew says this will be the first time this information has been collected and measured in the same way across the whole country.

“The results will help DHBs to make improvements in care and give the public valuable insights into the performance of their local health services,” says Mrs Goodhew

“The new survey, which was developed by the Health Quality and Safety Commission, will be an important way of measuring the quality of health services.

That’s a very good idea – both getting patient feedback, but also having comparable data across hospitals.

Of course that data may be used to make one of those evil league tables, so I guess some parties will be against it!

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The healthcare portal

January 15th, 2014 at 12:00 pm by David Farrar

Stuff reports:

The face of New Zealand healthcare will change before the year is out as Kiwis are signed into patient portals allowing them to self-manage their medical records, book doctor appointments and chat to their GP online.

The new multi-million dollar electronic healthcare system is a hybrid of internet banking and social networking – giving patients a secure account to view their medical records and test results, but also a private platform to instantly message their GP.

National health IT board director Graeme Osborne said the patient portal service was “ground-breaking”. It would empower Kiwis to take control of their own healthcare.

More than 50 per cent of the country’s general practices would be using the service by the end of 2014, he said.

“This is more than a hope. Each region and each district in New Zealand will roll this out.”

Online services would initially include a list of the patient’s medical conditions and medications, notifications when laboratory test results were available, the ability to book doctor appointments and order repeat prescriptions online and a messaging system to email GPs for health advice.

That would be great. I’d love being able to book appointments online and being able to access my own test results.

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Prioritise health towards the young

November 25th, 2013 at 10:00 am by David Farrar

The Herald reports:

Dr Paul Hutchison, chairman of the health committee which this week made a raft of recommendations around early intervention health programmes, told TVNZ’s Q + A the Government needed to reprioritise the health budget to better address the needs of many young New Zealanders.

“This dollar spent very early on, not only improves the health outcome of the younger, it gives them the chance to be productive and lead highly functional contributory lives.”

I agree. For the same reasons I would spend more on early childhood education than tertiary education – you do the most good when young.

They key recommendations from the select committee chaired by Dr Hutchison are:

*Research the cost-effectiveness of early intervention programmes from pre-conception to three years within 12 months.

*Set a national health target for all women to have an antenatal assessment within the first 10 weeks of pregnancy.

*Make sexual education mandatory in all schools and increase access to long-acting contraceptives.

*Develop an action plan with NGOs and private sector for evidence-based nutrition programmes.

*Develop an action plan to combat fetal alcohol syndrome, introduce warning labels on alcohol products, and consider higher taxes on alcohol.

*Consider expansion of early childhood education services in poor areas.

*Prime Minister to take on a formal leadership role in developing a cross-agency plan for children’s health.

*Invest in a nationwide oral health campaign and transfer responsibility for fluoride additives to Ministry of Health and DHBs.

*Give support to funding for research on children’s health, and match it to international benchmarks.

 All looks pretty sensible and worthwhile.

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The desirability of part-payments for healthcare

October 21st, 2013 at 4:00 pm by David Farrar

Treasury announced:

Inaugural Treasury University Challenge Winner Announced The winner of the New Zealand Treasury’s inaugural University Challenge is Sarah Shier, a Master of International Business student at the University of Auckland.

Her essay on Health and the possibility of co-payments was judged the best among entries submitted by students from all of New Zealand’s universities and from a range of disciplines. Entrants were asked to write a 2000-word essay to answer one of three questions on Crown assets, health, and overseas investment.

“The calibre of Sarah Shier’s essay and those of the other finalists was very impressive,” says Deputy Secretary for Strategy, Change & Performance Bill Moran.

“In assessing pros and cons of extending part-payments in our health system, Sarah showed both sides of arguments and brought together evidence from several sources to make her case. She also looked at how different socioeconomic groups might be affected, anticipated issues, and put forward measures to address concerns. It was high-quality work and I congratulate Sarah on her success.

“This competition has been a success for the Treasury too. We wanted to give university students a feel for the range of work the Treasury does and let them test their analytical skills on real life policy issues. We also wanted to reward excellence in public policy analysis and the University Challenge was a great chance to do this.

“After this year’s success the Treasury is looking forward to running the University Challenge again in 2014.”

Winner Sarah Shier will receive $2,500 towards her university fees for 2014.

Well done Sarah. Her essay is here. Some extracts:

Increasing co-payments for costly medications creates the opportunity to improve patient access to clinically effective medicines. Additionally, expenditures would be reduced as patients opt for preventative treatments over costly hospitalisations. Co-payment reform would also address socioeconomic and ethnic inequalities in the healthcare system by ensuring that subsidies are provided for those who need them the most.

Nonetheless, if not structured correctly, increased patient payments may exacerbate ethnic healthcare inequalities in the status quo. Furthermore, policies ought to continue subsidising preventative care in order to reduce long-run healthcare expenditures.

And on PHARMAC:

Medical professionals argue that PHARMAC’s rationing policies have limited the availability of effective medications within New Zealand. A 2008 report indicated that “New Zealand has 84 fewer innovative medicines funded than Australia.” Limited availability of blood pressure and lipid level medication can be costly in the long run as patients seek more expensive treatment for largely preventable cardiovascular conditions. Cardiovascular disorders accounted for the largest percent of “avoidable hospitalisations” within a Canterbury Hospital study.

Increasing co-payments for medications that benefit patients but are restricted in the status quo would improve the quality and efficiency of the healthcare system. Funding limitations have driven PHARMAC to fund some medications for high risk individuals only. However, expanded usage of pharmaceuticals such as statins may benefit lower risk patients and strengthen the healthcare system by preventing unnecessary costs in the long run. Co-payments could be applied to drugs such as statins that are widely beneficial but expensive to provide.

And on targeting:

Although funding for low-income healthcare has increased, a disproportionate amount of current expenditures are spent on high decile areas. Since the late 1990s, healthcare funding has increased more for higher income deciles than the more needy lower income categories.

Increased expenditures on broad initiatives—such as the community-based Primary Healthcare Strategy— have been largely responsible for the discrepancy between deciles. As a result, combined spending on decile 1-5 areas dropped to 54% in 2010.

Under a co-payment reform plan, subsidies could be targeted towards low-income groups to ensure equitable treatment. Increased patient payments could be designated for higher income individuals with the means to afford a modest increase in their current co-pay.

I believe it is sensible to target health care subsidies to those on lower incomes, and have those better off pay for a larger proportion of their own health needs.

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Patient ranking for hospitals

October 20th, 2013 at 10:24 am by David Farrar

The SST report:

Patients will be able to write reviews of their public hospital stays when Trip Advisor-style ratings are adopted in New Zealand next year.

Health Minister Tony Ryall has confirmed a patient ranking system for public hospitals, similar to those already in use in Britain, will be rolled out nationwide.

It will allow patients to score hospitals on the quality of their emergency departments and inpatient wards and comment on what they liked or disliked, including staff, beds and food.

In Britain, the National Health Service introduced the Friends and Family test in April this year. Patients are surveyed and can write online reviews, giving hospitals and clinics star ratings on cleanliness, staff co-operation, dignity and respect, patient involvement and accommodation.

In New Zealand, the Health Quality & Safety Commission is working on a similar but more comprehensive version of the tests for our hospitals.

That’s a great idea. Public ratings and feedback can be a very effective way of incentivising high standards.

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Saint Göran Hospital

May 28th, 2013 at 3:00 pm by David Farrar

The Economist reports:

SAINT GORAN’S hospital is one of the glories of the Swedish welfare state. It is also a laboratory for applying business principles to the public sector. The hospital is run by a private company, Capio, which in turn is run by a consortium of private-equity funds, including Nordic Capital and Apax Partners. The doctors and nurses are Capio employees, answerable to a boss and a board. Doctors talk enthusiastically about “the Toyota model of production” and “harnessing innovation” to cut costs.

A hospital owned by equity funds and run like a car company? The instinct would be to deplore it as everything that a hospital shouldn’t be. But what is the reality?

The hospital today is organised on the twin lean principles of “flow” and “quality”. Doctors and nurses used to keep a professional distance from each other. Now they work (and sit) together in teams. (Goran Ornung, a doctor, likens the teams to workers in Formula One pit stops.) In the old days people concentrated solely on their field of medical expertise. Now they are all responsible for suggesting operational improvements as well.

So staff are empowered.

One innovation involved buying a roll of yellow tape. Staff used to waste precious time looking for defibrillator machines and the like. Then someone suggested marking a spot on the floor with yellow tape and insisting that the machines were always kept there. Other ideas are equally low-tech. Teams use a series of magnetic dots to keep track of each patient’s progress and which beds are free. They discharge patients throughout the day rather than in one batch, so that they can easily find a taxi.

The best ideas are often simple. My staff came up with the idea of using Facebook to organise rosters. It turned what was teh most challenging part of our operations to simplicity – as it allowed staff to arrange their own replacements.

St Goran’s is the medical equivalent of a budget airline. There are four to six patients to a room. The decor is institutional. Everything is done to “maximise throughput”. The aim is to give taxpayers value for money. Hospitals should not be in the hotel business, the argument goes. St Goran’s has reduced waiting times by increasing throughput. It has also reduced each patient’s likelihood of picking up an infection. However, scrimping on hotel services means that it has to invest in preparing patients for admission and providing support after they are released.

Sounds all positive. Reduced waiting times, reduced infections, better pre and post admission support.

Sweden has gone further than any other European country in embracing the purchaser-provider split—that is, in using government money to buy public services from whichever providers, public or private, offer the best combination of price and quality. Private firms provide 20% of public hospital care in Sweden and 30% of public primary care. Both the public and private sectors are obsessed with lean management; they realise that a high-cost country such as Sweden must make the best use of its resources.

I think it is a pity the funder provider split was never fully implemented in NZ.

St Goran’s also acts as a hare for Capio, one of Europe’s largest health-care companies, with 11,000 employees across the continent and 2.9m visits from patients in 2012. Sweden is Capio’s biggest market, accounting for 48.2% of its sales (France comes second with 37.6%). The firm performs 10% of all Swedish cataract operations, and much more besides. Capio thinks it can make huge savings in other countries by transferring the lessons it has learned in Sweden. The average length of a hospital stay in Sweden is 4.5 days, compared with 5.2 days in France and 7.5 days in Germany. Sweden has 2.8 hospital beds per 1,000 citizens. France has 6.6; Germany, 8.2. Yet Swedes live slightly longer.

A great stat.

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Food stupidity from Labour

April 12th, 2013 at 1:00 pm by David Farrar

Stuff reports:

Patients could be fed week-old food under Government plans for hospitals, leaked documents have revealed.

A report obtained by TV3 News yesterday showed food would be made in two hubs, in Christchurch and Auckland, and then transported to hospitals across the country, saving $10 million.

Some of the food could be chilled for up to a week before being served. …

Labour Health spokeswoman Annette King said the move was ‘‘a shocker’’.

‘‘I’m trying to imagine what a silver beet looks like after six and half days in the chiller,’’ she said.

‘‘It can’t be good for patients to be fed food cooked and chilled for up to seven days.’’

A Health spokesperson should be more responsible that suggesting chilled food is unsafe.

Millions of NZers eat food that has been chilled and then reheated.

It really is pathetic, this type of mindless opposition.

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What do we want our health dollars spent on?

April 11th, 2013 at 12:00 pm by David Farrar

The Herald reports:

The Government is refusing to say how many jobs could be lost in a proposed overhaul of the provision of hospital meals that would save up to $175 million over 15 years.

The plan has been drawn up by Health Benefits Limited (HBL), a Government-owned organisation set up to find savings by reducing duplication and administration costs.

Health Minister Tony Ryall confirmed there would be staffing cuts and didn’t rule out closing or downsizing some of New Zealand’s 39 hospital kitchens operated by 20 district health boards.

But Mr Ryall said the quality of meals provided to patients would be paramount and not compromised by the changes.

If the DHBs can save money with more efficient meal costs, and no change in quality, then of course it should and must do it.

The purpose of the health system is to help sick people get well. Not to create jobs for kitchen workers.

The more money one can save on support services, the more money available for surgeries, drugs, cancer treatment etc.

Compass already provides a third of health board meals, Spotless Services another third, and local providers the rest.

So two thirds already contract the service out. Not surprised the DHBs have realised that one national contract could cost a lot less than 39 separate contracts.

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Elective Surgeries

August 16th, 2012 at 1:53 pm by David Farrar

Tony Ryall has announced:

“An extra 7,500 patients received elective surgery in the last 12 months, meaning 153,000 people got the operations they needed. This is the fourth year of record increases under National,” said Health Minister Tony Ryall.

“Since the change of government in 2008, thirty per cent more patients are getting elective surgery.

This is a pretty incredible achievement when you consider the fiscal environment.

It shows what you can achieve by having a more focused and efficient health system.

My only wish is Ryall goes further and defunds all the public health lobby groups which campaign for nanny state policies, and puts the money saved into elective surgery.

“In the last year the number of patients across the country waiting longer than six months has been reduced by eighty-five per cent from 5,700 to 840.

“This includes 690 patients on Canterbury DHB’s list which has been exempted from the target this year. Not counting Canterbury, this means that now only 150 patients who are booked to see a specialist or for surgery are waiting more than six months across the country at any one time.

So now only 150 people now waiting more than six months? What was the figure in 2008 I wonder?

“The challenge is now to lock in the goal of zero patients waiting over six months, and then bring the maximum waiting time down to five months by the end of June 2013,” Mr Ryall says.

No resting on the laurels.

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Prescription Charges

May 15th, 2012 at 11:00 am by David Farrar

Tracy Watkins at Stuff reports:

Prescription charges will increase from $3 an item to $5 an item in next week’s Budget, as the Government moves to offset the cost of extra health spending in the “zero Budget”.

The new charge will cover up to a maximum of 20 items from January 1 next year, raising $20m in the first year and $40m after that.

Health Minister Tony Ryall and Prime Minister John Key said the money raised would be  reinvested in the health sector.

“Despite tight financial times and what will be a zero Budget on May 24, health will receive a big funding boost, which will come from savings within health and across the Government’s accounts,” Ryall said.

It was the first time the prescription charge has been increased in 20 years. There will continue to be no charge for under-sixes.

Despite this Hone Harawira is claiming children will die because of this.  Anything for a cheap headline.

The fee used to be $15, and Labour in 2004 reduced it to $3. This increase is a maximum $40 per year per person, so I don’t think will be a huge impact for most. The Government noted:

New Zealand continues to have low prescription charges compared to almost every other developed country.

In Australia, for example, the standard prescription charge is up to NZ$45 and in England it’s around NZ$16. In Australia people on low incomes pay around NZ$7.45 per item. In Finland, there is an annual limit of around NZ$1,107 per patient, after which there is a flat fee of around NZ$2.50 per medicine item.

I think Australia has the right idea. It is hugely economically inefficient to provide subsidies to wealthy people who don’t need them. We spend just over $1 billion a year on subsidized medicines.

What Id like to see happen is that low income people with a community services card get their medicine highly subsidized (pay only $3 to $5), while others pay somewhere between most and all of the cost themselves.

The real challenge for this Government is to reduce the huge amount of middle class welfare we have.  We can support those less well off better, if we are not subsidizing medicines for millionaires.

UPDATE: The maximum possible extra cost per person family works out at 11c a day. This puts into context the hysterical claims by Harawira which the media are giving such prominence to.

So this week we have the offer of free voluntary contraception to beneficiaries being compared to Nazi war crimes by Josef Mengele, and a maximum 11c a day rise in the cost of prescriptions to killing children. Some on the left are getting rather demented.

 

 

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Smoking Targets

April 16th, 2012 at 1:00 pm by David Farrar

Labour’s Iain Lees-Galloway has said:

The Government is deliberately ignoring health data that doesn’t tell the story it wants the public to hear, Labour’s Associate Health spokesperson Iain Lees-Galloway says.

“Statistics collected by the Ministry of Health reveal that every district health board (DHB) except one is failing to get close to acceptable rates for early smoking cessation intervention.

“The Government wants us to believe it has made smoking cessation a priority. These figures highlight the reality – it hasn’t, “Iain Lees-Galloway.

“The Ministry of Health expects 90 per cent of smokers who see a GP to be provided with advice and help to quit, yet only one DHB is reaching that target.

“No other DHB is even close. In fact, on average they are underperforming by 57%.

“Tony Ryall, of course, is allergic to bad news, so these figures never get reported.

 “Interestingly he talks up statistics around smokers who end up in hospital* and the advice they get there.

“But only reporting smoking cessation activities in hospitals is ludicrous. Far more people see their GP than go to hospital.

This is an interesting issue. Lees-Galloway is taking about two seperate things – the proportion of smokers who see their GP who get advice and help to quit, and the proportion of smokers in a hospital who get advice and help to quit.

The hospital figure is the official national health target. It was 90% and has just gone up to 95%. The DHB average was 95% in the first quarter of 2011/12 and slipped back to 89% in the second quarter. Six DHBS made 95% and 12 made 90%, while eight did not.

Now hospitals are actually run by DHBs. DHBs control hospitals. A DHB has the ability to put in place policies around offering quit smoking services to patients. Also be aware that the average person spends hours or days in hospital, so it is easier to do something additional to the reason they are in hospital.

GPs are not employed by DHBs. They are private entities, that only get a portion of their income from the Government. The ability of a Government to get GPs to do something is very limited, and frankly it is silly of Lees-Galloway to think they can.

Now from what I can tell, the DHBs only started funding GPs to even code their patients as to whom are smokers and non-smokers. Sure it is recorded in notes in long-hand, but it is a big job to go through every file and mark them in the database as a smoker.

The new target for GPs only started this year, and they noted:

Unlike the other health targets, this measure started from scratch as provision of advice and help to smokers was not recorded previously nor even offered routinely.

So imagine what is involved to get every GP in NZ recording the status, and then also recording if they offered quit smoking assistance. I’ve worked in a medical centre. The average visit is around 15 minutes, and covering anything apart from the immediate problem slows things down a lot. Now this is not to say it is not a good idea – it is. But expecting 90% achievement in the first year is silly.

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Oh dear some awful income inequality

February 4th, 2012 at 10:23 am by David Farrar

Martin Johnston at NZ Herald reports:

Some Auckland surgeons are being paid more than $6000 for a day’s work at a public hospital.

My God. They are part of the 1% scum.

The Waitemata District Health Board scheme has divided doctors over concerns that the surgeons involved can earn nearly four times as much as general physicians and psychiatrists on their collective agreement’s top step.

Income inequality alert. This is evil and must be stopped.

The Waitakere “pilot” project pays orthopaedic surgeons a contract rate of $2200 for each total hip or knee replacement package of care. This comprises $1320 for the operation plus $880 for daily patient review, any call-backs during the hospital stay, availability for six weeks after surgery and a six-week visit.

A fixed cost per operation. We can’t have that.

On the union-negotiated multi-employer collective agreement, specialists of all kinds on the highest step earn an annual base salary of $206,000, or $99 an hour, but this increases to around $170 an hour when leave, KiwiSaver and allowances are factored in. Some specialists are paid above the collective’s rates.

Good God, they get paid even more than stevedores.

Senior doctors’ union executive director Ian Powell said the split rates undermined the team-work that was critical to the safety of patients in a complex public hospital.

Oh yes, because one doctor is paid more than another, they will compromise patient safety. I have to say I don’t know any doctors like that.

So why is the DHB doing this nasty income inequality with its doctors?

DHB chairman Lester Levy said the pilot had worked very well.

The rates paid to orthopaedic surgeons were around 60 per cent of private-sector rates. The scheme had led to a number of surgeons opting to do less private-sector work in favour of doing most of their work on public patients.

Productivity was up by a third. Costs shrank 12 per cent for hips and 16 per cent for knees because of a 40 per cent reduction in patients’ average length of stay in hospital, less time in theatre and fewer staff being involved in treatment.

Bringing previously out-sourced surgery in-house saved the DHB $3 million in the last financial year. Patient satisfaction was high and the transfer rate to North Shore Hospital was low.

So paying some staff more has saved the DHB money, improved productivity, reduced lengths of stays in hospitals, increased patient satisfaction and reduced the transfer rate.

But despite this, the union is against this because not all staff are paid more, only some.

Labour should be welcoming what Lester Levy is doing. Rather than contract their operations out to the private sector, the Waitemata DHB is now doing them in-house.

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